ORIGINAL REPORTS
Perceptions, Training Experiences, and Preferences of Surgical Residents Toward Laparoscopic Simulation Training: A Resident Survey Shohan Shetty, MD,* Boris Zevin, MD,† Teodor P. Grantcharov, MD, PhD, FACS,† Kurt E. Roberts, MD, FACS,‡ and Andrew J. Duffy, MD, FACS‡ The Stanley J. Dudrick Department of Surgery, Saint Mary’s Hospital, Waterbury, Connecticut; †Department of Surgery, University of Toronto, Toronto, Ontario, Canada; and ‡Department of Surgery, Yale University School of Medicine, New Haven, Connecticut *
INTRODUCTION: Simulation training for surgical residents
can shorten learning curves, improve technical skills, and expedite competency. Several studies have shown that skills learned in the simulated environment are transferable to the operating room. Residency programs are trying to incorporate simulation into the resident training curriculum to supplement the hands-on experience gained in the operating room. Despite the availability and proven utility of surgical simulators and simulation laboratories, they are still widely underutilized by surgical trainees. Studies have shown that voluntary use leads to minimal participation in a training curriculum. Although there are several simulation tools, there is no clear evidence of the superiority of one tool over the other in skill acquisition. The purpose of this study was to explore resident perceptions, training experiences, and preferences regarding laparoscopic simulation training. Our goal was to profile resident participation in surgical skills simulation, recognize potential barriers to voluntary simulator use, and identify simulation tools and tasks preferred by residents. Furthermore, this study may help to inform whether mandatory/protected training time, as part of the residents’ curriculum is essential to enhance participation in the simulation laboratory. METHODS: A cross-sectional study on general surgery residents
(postgraduate years 1-5) at Yale University School of Medicine
Presented at the 8th Annual Academic Surgical Congress (February 5-7, 2013) in New Orleans, LA. Financial disclosures: Dr Teodor Grantcharov has a research grant from Covidien, Canada, and a research grant from Johnson and Johnson Inc, Canada. Dr Kurt Roberts has provided consultancy services for Covidien, participated in a Covidiensponsored grant, and has a patent pending with NovaTract. Correspondence: Inquiries to Shohan Shetty, MD, The Stanley J. Dudrick Department of Surgery, Saint Mary’s Hospital, 56 Franklin Street, Waterbury, CT 06706; fax: (203) 709-6089; e-mail: [email protected]
and the University of Toronto via an online questionnaire was conducted. Overall, 67 residents completed the survey. The institutional review board approved the methods of the study. RESULTS: Overall, 95.5% of the participants believed that
simulation training improved their laparoscopic skills. Most respondents (92.5%) perceived that skills learned during simulation training were transferrable to the operating room. Overall, 56.7% of participants agreed that proficiency in a simulation curriculum should be mandatory before operating room experience. The simulation laboratory was most commonly used during work hours; lack of free time during work hours was most commonly cited as a reason for underutilization. Factors influencing use of the simulation laboratory in order of importance were the need for skill development, an interest in minimally invasive surgery, mandatory/protected time in a simulation environment as part of the residency program curriculum, a recommendation by an attending surgeon, and proximity of the simulation center. The most preferred simulation tool was the live animal model followed by cadaveric tissue. Virtual reality simulators were among the least-preferred (25%) simulation tools. Most residents (91.0%) felt that mandatory/protected time in a simulation environment should be introduced into resident training protocols. CONCLUSIONS: Mandatory and protected time in a
simulation environment as part of the resident training curriculum may improve participation in simulation training. A comprehensive curriculum, which includes the use of live animals, cadaveric tissue, and virtual reality simulators, may enhance the laparoscopic training experience and C 2014 interest level of surgical trainees. ( J Surg ]:]]]-]]]. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.01.006
1
KEY WORDS: surgical education, laparoscopic skills training, resident participation, simulation, curriculum COMPETENCIES: Practice Based Learning and Improve-
ment, Systems Based Practice
INTRODUCTION Recent advances in surgical techniques, laparoscopic surgery in particular, require surgeons to master a unique set of psychomotor and visuospatial skills.1-6 These skills are necessary to overcome the specific challenges introduced by the laparoscopic approach: loss of depth perception, altered hand-eye coordination, changes in tactile feedback, the fulcrum effect, and working with elongated instruments. Other challenges facing surgical training today include work-hour limits, increased patient volume, demands for efficiency, and evolving requirements for objective proficiency. Simulation training for surgical residents can shorten learning curves, improve technical skills, and expedite competency. Furthermore, as numerous inherent traits and technical skill aptitudes affect individual learning, relying on an obligatory number of procedures performed in the operating room as the sole measure of proficiency may result in graduates with variable skills.7,8 As a result, much effort has been focused on developing efficient and effective training strategies for surgical residents and students in an environment outside the operating room, such as a surgical skills laboratory.9,10 Several studies have shown that technical skills learned in a simulation environment are transferrable to the operating room.4,11,12 Despite these positive and encouraging results, most surgical training programs continue to struggle with the integration of simulation-based training into the residents’ curricula,13 and simulation laboratories continue to be underutilized by surgical trainees.14 Chang et al.15 found that voluntary use of a simulation laboratory leads to minimal resident participation and mandatory participation was required for the training curriculum to be effective. Effective training tools in a skills laboratory include video box trainers, computer-based virtual reality (VR) simulators, inanimate models, and live animal models; however, there is no clear evidence of the superiority of one simulation tool over the other in skill acquisition.16 Furthermore, opinions regarding the most effective simulation tool differ between surgical educators and trainees.17,18 There is currently a paucity of data regarding residents’ opinions on minimally invasive simulation training. The purpose of this study was to explore resident perceptions, training experiences, and preferences regarding laparoscopic simulation training. Our goal was to profile resident participation in surgical skills simulation, recognize potential barriers to voluntary simulator use, and identify simulation tools and tasks preferred by residents before incorporating them into a formal skills training curriculum. 2
MATERIALS AND METHODS General surgery residents (postgraduate years [PGYs] 1-5) were recruited from Yale University School of Medicine, New Haven, CT, United States and the University of Toronto, Toronto, Ontario, Canada. Both institutions involved in this study had simulation laboratories available for use by general surgery residents. These laboratories house video box trainers, VR simulators, inanimate hernia models, and explanted tissue models. All residents also had scheduled sessions to practice on live anesthetized animal models as part of approved research protocols. Data were collected using an anonymous online questionnaire (www.surveymonkey.com) administered between November 1 to 31, 2011 and June 1 to 30, 2012. Two e-mail reminders were sent during each cycle of questionnaire administration. The questionnaire included 21 questions structured in rank-order, Likert-type, single answer, and multiple-choice formats. Demographics data, such as age, sex, level of training, and position type, were obtained. Questionnaire responses were coded and analyzed using STATA 12.1 (StataCorp, College Station, TX). Number “1” was defined as the highest possible rank for rank-order questions. Responses to rank-order questions were analyzed using one-way analysis of variance with Bonferroni post hoc correction for repeated measures. Likert-type questions required participants to provide responses on a scale from 1 to 5 corresponding to “Strongly Disagree,” “Disagree,” “Neutral,” “Agree,” and “Strongly Agree.” For the graphical representation of results, participants’ responses of “Agree” and “Strongly Agree” were combined into one “Agree” category and responses of “Disagree” and “Strongly Disagree” were combined into one “Disagree” category. The Fisher exact test was used for statistical analysis of Likert-type responses. This study was approved by the research ethics board of the University of Toronto and by the human investigation committee at Yale University School of Medicine. Informed consent was obtained if the participants chose to complete the online survey.
RESULTS A total of 43 of 78 (55.1%) residents at the University of Toronto and 24 of 67 (37.3%) residents at Yale University School of Medicine completed the online questionnaire, resulting in a combined response rate of 46.5%. The participants’ demographic data are presented in Table 1. With regard to ranking of model preferences by an entire group of study participants, live anesthetized animal was the most preferred model and the inanimate hernia model was the least preferred one (Table 2). There were significant differences between mean rank scores at p o 0.05 for the 5 models (F (4, 321) ¼ 10.45, p ¼ 0.0000). In post hoc comparisons, the mean rank score for live animal model was Journal of Surgical Education Volume ]/Number ] ] 2014
TABLE 1. Demographic Data for Questionnaire Participants University of Toronto Number of respondents (n; response rate %) Age (mean ⫾ SD [y]) Male (n; %) Female (n; %) Level of training (PGY) 1 2 3 4 5 Training position Categorical (n; %) Noncategorical (n; %) Fellowship interest Undecided Colon and rectal surgery Hand surgery Bariatric and minimally invasive surgery Pediatric surgery Plastic surgery Surgical oncology Surgical critical care/trauma/burn Thoracic surgery Transplantation Vascular surgery Other specialty
43 29.5 26 17 1 8 17 7 10
(55.1) ⫾ 3.1 (60.5) (39.5)
Yale University 24 29.5 19 5
(2.3%) (18.6%) (39.5%) (16.2%) (23.2%)
5 7 4 5 3
43 (100) 0
(37.3) ⫾ 2.1 (79.2) (20.8) (20.8%) (29.2%) (16.7%) (20.8%) (12.5%)
21 (87.5) 3 (12.5)
17 (39.5%) 1 (2.3%) 0 10 (23.3%) 1 (2.3%) 0 8 (18.6%) 1 (2.3%) 0 0 3 (7.0%) 2 (4.7%)
6 (25.0%) 3 (12.5%) 0 1 (4.2%) 2 (8.3%) 3 (12.5%) 2 (8.3%) 0 3 (12.5%) 1 (4.2%) 3 (12.5%) 0
Total 67 29.5 45 22 6 15 21 12 13
(46.5) ⫾ 2.8 (67.2) (32.8) (9.0%) (22.4%) (31.3%) (17.9%) (19.4%)
64 (95.5) 3 (4.5) 23 (34.3%) 4 (6.0%) 0 11 (16.4%) 3 (4.5%) 3 (4.5%) 10 (14.9%) 1 (1.5%) 3 (4.5%) 1 (1.5%) 6 (9.0%) 2 (3.0%)
SD, standard deviation.
significantly different (p o 0.05) from each of the other 4 models. The mean rank scores for video box trainer, VR simulator, inanimate hernia model, and explanted tissue were not significantly different from each other (p 4 0.05). However, the rankings for simulation models did differ based on a participant’s PGY of training (Fig. 1). PGY 1 trainees preferred video box trainers and VR simulators. PGY 2 trainees preferred live animal models and box trainers. PGYs 3 and 4 trainees preferred live animal models and practice on explanted tissues, whereas PGY 5 trainees preferred live animal models and box trainers. Intracorporeal knot tying was the most commonly practiced simulation task (Table 3). There were significant differences between the mean rank scores at p o 0.05 for the 6 commonly practiced simulation tasks (F (5, 378) ¼ 6.25, p ¼ 0.0000). In post hoc comparison, the mean rank score for intracorporeal knot tying was significantly different from pattern cutting (p ¼ 0.032), VR simulator–based curriculum (p ¼ 0.007), and VR simulator–based operative
procedure (p ¼ 0.000). The mean rank score for peg transfer was also significantly different from the mean rank score for the VR simulator–based operative procedure (p ¼ 0.003). The mean rank scores were not significantly different between all other commonly practiced tasks. Skill development, interest in minimally invasive surgery, and mandatory or protected time were cited as the top 3 reasons for using the simulation laboratory (Table 4). There were significant differences between the mean rank scores at p o 0.05 for the 9 reasons for using a simulation laboratory (F (8, 551) ¼ 18.28, p ¼ 0.0000). The top 2 reasons for residents not using a simulation laboratory were lack of time and being off campus for clinical rotations (Table 5). There were significant differences between the mean rank scores at p o 0.05 for the 4 reasons for not using a simulation laboratory (F (3, 256) ¼ 70.16, p ¼ 0.0000). In post hoc comparison, significant differences were demonstrated between the mean rank scores of the top 3 reasons of “lack of time,” “off campus/
TABLE 2. Ranking of Preferred Simulation Models Rank 1 2 2 4 5
Simulation Model
Mean Rank Score
Standard Error
Standard Deviation
Live animal model Explanted tissue Video box trainer Virtual reality simulator Inanimate hernia model
2.14 3.00 3.00 3.23 3.58
0.20 0.13 0.17 0.16 0.15
1.64 1.08 1.38 1.32 1.21
Journal of Surgical Education Volume ]/Number ] ] 2014
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FIGURE 1. Participants rankings of simulation models analyzed by postgraduate year of training.
off site,” “not necessary,” and the last reason of “not interested.” With regard to the timing of practice in a simulation laboratory, participants ranked “during work hours” as their top choice, followed by “postcall” and “off duty/on vacation” (Table 6). There were no significant differences between the mean rank scores at p o 0.05 for the 3 times for using a simulation laboratory (F (2, 196) ¼ 1.18, p ¼ 0.3095). The median amount of time that residents practiced per week in a simulation laboratory was 1 (0-1) hour. Simulators, which were used most of the time, were video box trainers (n ¼ 35; 68.6%) and VR simulators (n ¼ 4; 27.5%). Cadaveric tissue models (n ¼ 1; 2.0%) and inanimate models (e.g., hernia) (n ¼ 1; 2.0%) were rarely used. Only 2 of the 67 (3.0%) participants reported having a video box trainer at home; however, despite the availability of that simulator, the median amount of time practiced per week was only 1 (0-2) hour. Participants were also asked to comment on the need for mandatory time in a simulation laboratory. Of the 67 participants, 61 (91.0%) felt that mandatory participation in a simulation laboratory was essential. The median
number of hours suggested for practice in a simulation laboratory was 2 (2-3) hours per week. Participants were also asked to provide their opinions on the following 4 questions: Does simulation-based training improve laparoscopic skills? Are the skills acquired in a simulation laboratory transferable to the operating room? Is simulation training a good substitute for operating room exposure? Should a simulation-based curriculum be made mandatory before operating room exposure? Combining participants’ responses of “Agree” and “Strongly Agree” into one “Agree” category and responses of “Disagree” and “Strongly Disagree” into one “Disagree” category, 64 (95.5%) of the 67 participants agreed that simulationbased training improves laparoscopic skills (p o 0.0001) (Fig. 2). Of the 67 participants, 62 (92.5%) agreed that skills acquired in a simulation laboratory are transferable into the operating room (p o 0.0001). Of the 67 participants, 43 (64.2%) disagreed that simulation training is a good substitute for operating room exposure (p o 0.0001), whereas 38 (56.7%) agreed that proficiency in a simulationbased curriculum should be mandatory before operating room exposure (p ¼ 0.0019).
TABLE 3. Ranking of Commonly Practiced Simulation Tasks Rank 1 2 3 4 5 6
4
Simulation Task Intracorporeal knot tying Peg transfer Extracorporeal knot tying Pattern cutting Virtual reality simulator–based curriculum Virtual reality simulator–based operative procedure
Mean Rank Score
Standard Error
Standard Deviation
2.73 3.08 3.38 3.64 3.77 4.18
0.24 0.17 0.22 0.16 0.23 0.21
1.89 1.37 1.73 1.26 1.84 1.73
Journal of Surgical Education Volume ]/Number ] ] 2014
TABLE 4. Ranking of Reasons for Using the Simulation Laboratory Rank 1 2 3 4 5 6 7 8 9
Reason
Mean Rank Score
Standard Error
Standard Deviation
Skill development Interest in minimally invasive surgery Mandatory or protected time Practice before a case Requirement for a rotation Recommendation of an attending surgeon Proximity to the simulation lab Free time Peer pressure
2.48 4.23 4.35 4.87 5.32 5.39 5.56 5.57 7.11
0.28 0.32 0.35 0.26 0.30 0.26 0.28 0.28 0.32
2.22 2.54 2.73 2.06 2.38 2.11 2.23 2.15 2.49
DISCUSSION We used a cross-sectional survey design to characterize general surgery trainees from 2 academic training programs in North America in terms of demographics, attitudes, training experiences, and preferences toward laparoscopic simulation training. The anonymous and voluntary nature of the online survey encouraged true reporting and minimized reporting bias. Our study revealed several interesting findings. Overall, the high-fidelity live animal model was the most preferred simulation tool. The advantages of these models are the realism of the tissue, similarity to human anatomy, and opportunities to mimic intraoperative complications. The disadvantages of these models are the costs, requirement for mentor supervision, and ethical concerns regarding the use of live animals.16 Having had more experience in the operating room, the senior residents preferred the live animal model, possibly perceiving the VR simulation and inanimate models as less stimulating. Overall, VR simulation was among the least-favored simulation tool among the residents. This is in contrast to the opinion of surgical educators who perceive VR simulators as one of the most effective tools, second only to the operating room experience.17 From the surgical educator’s perspective, VR simulation affords minimal supervision during training, versatile customized curricula, opportunity
for deliberate practice, and an objective means for tracking trainee performance.19 Such models also allow the user to simulate complications in a risk-free environment. However, the trainees notice a lack of realism in the graphics and find the forced feedback, when available, to be limited or unrealistic. VR simulators also have a high initial start-up cost, and there are a large variety of simulators in the market offering a wide range of tasks, curricula, and procedures, thus making comparisons and validation difficult.16 Our study highlights potential trainee resistance among senior residents to learning on these models. Interestingly, our study showed that simulation tool preferences vary with the resident’s training level. We found that junior surgical residents prefer to train on VR simulators and box trainers, whereas senior residents prefer to train on live animal and explanted tissue models. This information can be considered by surgical educators when developing simulation-based training curricula. Junior residents can be started on VR simulators, and their skills can be improved by using validated and customized proficiencybased curricula,20,21 thus minimizing the need for mentor supervision. Senior residents can practice on explanted tissue and live animal models with appropriate faculty supervision, thereby using valuable faculty resources most effectively. We must also emphasize that training on a simulator in isolation may not be as beneficial as training on various
TABLE 5. Ranking of Reasons for Not Using the Simulation Laboratory Rank 1 2 3 4
Reason
Mean Rank Score
Standard Error
Standard Deviation
Lack of time Off campus/off site rotation Not necessary Not interested
1.61 1.88 3.02 3.42
0.12 0.09 0.09 0.12
0.97 0.70 0.70 0.96
TABLE 6. Ranking of Times for Using a Simulation Laboratory Rank 1 2 3
Timing
Mean Rank Score
Standard Error
Standard Deviation
During work hours Postcall Off duty/on vacation
1.92 1.94 2.12
0.12 0.08 0.10
0.95 0.67 0.81
Journal of Surgical Education Volume ]/Number ] ] 2014
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FIGURE 2. Participants’ opinions as rated on a Likert-type scale.
simulation models as part of a comprehensive training curriculum that addresses multiple components of surgical competency. Clinical performance should be assessed using objective, reliable, and valid assessment tools for technical and nontechnical skills. One algorithm to follow in designing such curricula is to use a recently published framework for design, validation, and implementation of simulationbased training curricula in surgery.22 Palter and Grantcharov23 recently demonstrated how to develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. The most commonly practiced tasks by the residents were the Fundamentals of Laparoscopic Surgery (FLS) tasks and intracorporeal knot tying in particular. An increased use of the video box trainer was noticed among the fifth-year residents to perform these tasks. A factor responsible for this may be the requirement for Fundamentals of Laparoscopic Surgery certification during the fifth year to qualify for the American Board of Surgery examination. As expected, internal motivating factors, such as skill development and a fellowship interest in minimally invasive surgery, were the most often cited reasons for using the simulation laboratory. However, work-hour restrictions, clinical responsibilities, and limited free time often negatively affect internal motivating factors. An external motivating factor, such as mandatory and protected time— instituted rarely in our institutions—was another common reason for simulator use. Most residents believed that simulation training improved skills and transferred to the operating room, yet few found the time during their workweek to practice their skills. Should the onus to make the time for simulation training be up to each individual resident? Studies have shown that introducing mandatory participation in simulation training with punitive measures for low attendance improves participation.14 Currently, the core of the mandatory education curriculum for most residency programs consists of scheduled teaching conferences, didactic sessions, grand rounds, journal clubs, and mock oral examinations. The time spent in these educational activities is counted toward duty hours to be compliant with the Accreditation
Council for Graduate Medical Education (ACGME) Program requirements.24 Our study shows that an overwhelming majority of residents were in favor of incorporating at least 2 hours per week of mandatory/protected time in a simulation environment as part of the resident education curriculum. This study has a number of strengths and adds to the literature in many ways. First, it successfully elicits trainee perceptions and experiences and identifies varying preferences among training levels. Second, this study also demonstrates common barriers to voluntary participation and provides an insight into the discrepancy between what residents desire and what is current practice. Third, the study also includes residents from 2 institutions with different training systems, which may add to the generalizability of the results. This study has a few limitations. First, it has a relatively low response rate; however, this is in keeping with survey responses among physicians.25 Second, this study includes participants from 2 similar academic training programs; both with well-equipped simulation laboratories. Third, these findings may not generalize to smaller programs, and larger studies at a national level are required to further investigate these findings.
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Journal of Surgical Education Volume ]/Number ] ] 2014
CONCLUSION This study informs us about resident preferences and training patterns, which could be factored when setting up a surgical skills curriculum. A comprehensive curriculum that includes the optimal use of the live animal models, video box trainers, and VR simulators with structured proctoring during the sessions may enhance the laparoscopic training experience for surgical trainees.
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RP. Resident training in minimally invasive surgery: a survey of Canadian department and division chairs. Surg Endosc. 2010;24(3):499-503. 18. Palter VN, Orzech N, Aggarwal R, Okrainec A,
Grantcharov TP. Resident perceptions of advanced laparoscopic skills training. Surg Endosc. 2010;24(11): 2830-2834. 19. Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills
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and validating a customized virtual reality-based laparoscopic skills curriculum. J Surg Educ. 2008;65(6): 413-417. 22. Zevin B, Levy JS, Satava RM, Grantcharov TP. A
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12. Ahlberg G, Heikkinen T, Iselius L, Leijonmarck CE,
24. Accreditation Council for Graduate Medical Education
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Journal of Surgical Education Volume ]/Number ] ] 2014
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Perceptions, Training Experiences, and Preferences of Surgical Residents Toward Laparoscopic Simulation Training: A Resident Survey Shohan Shetty, MD,* Boris Zevin, MD,† Teodor P. Grantcharov, MD, PhD, FACS,† Kurt E. Roberts, MD, FACS,‡ and Andrew J. Duffy, MD, FACS‡ The Stanley J. Dudrick Department of Surgery, Saint Mary’s Hospital, Waterbury, Connecticut; †Department of Surgery, University of Toronto, Toronto, Ontario, Canada; and ‡Department of Surgery, Yale University School of Medicine, New Haven, Connecticut *
INTRODUCTION: Simulation training for surgical residents
can shorten learning curves, improve technical skills, and expedite competency. Several studies have shown that skills learned in the simulated environment are transferable to the operating room. Residency programs are trying to incorporate simulation into the resident training curriculum to supplement the hands-on experience gained in the operating room. Despite the availability and proven utility of surgical simulators and simulation laboratories, they are still widely underutilized by surgical trainees. Studies have shown that voluntary use leads to minimal participation in a training curriculum. Although there are several simulation tools, there is no clear evidence of the superiority of one tool over the other in skill acquisition. The purpose of this study was to explore resident perceptions, training experiences, and preferences regarding laparoscopic simulation training. Our goal was to profile resident participation in surgical skills simulation, recognize potential barriers to voluntary simulator use, and identify simulation tools and tasks preferred by residents. Furthermore, this study may help to inform whether mandatory/protected training time, as part of the residents’ curriculum is essential to enhance participation in the simulation laboratory. METHODS: A cross-sectional study on general surgery residents
(postgraduate years 1-5) at Yale University School of Medicine
Presented at the 8th Annual Academic Surgical Congress (February 5-7, 2013) in New Orleans, LA. Financial disclosures: Dr Teodor Grantcharov has a research grant from Covidien, Canada, and a research grant from Johnson and Johnson Inc, Canada. Dr Kurt Roberts has provided consultancy services for Covidien, participated in a Covidiensponsored grant, and has a patent pending with NovaTract. Correspondence: Inquiries to Shohan Shetty, MD, The Stanley J. Dudrick Department of Surgery, Saint Mary’s Hospital, 56 Franklin Street, Waterbury, CT 06706; fax: (203) 709-6089; e-mail: [email protected]
and the University of Toronto via an online questionnaire was conducted. Overall, 67 residents completed the survey. The institutional review board approved the methods of the study. RESULTS: Overall, 95.5% of the participants believed that
simulation training improved their laparoscopic skills. Most respondents (92.5%) perceived that skills learned during simulation training were transferrable to the operating room. Overall, 56.7% of participants agreed that proficiency in a simulation curriculum should be mandatory before operating room experience. The simulation laboratory was most commonly used during work hours; lack of free time during work hours was most commonly cited as a reason for underutilization. Factors influencing use of the simulation laboratory in order of importance were the need for skill development, an interest in minimally invasive surgery, mandatory/protected time in a simulation environment as part of the residency program curriculum, a recommendation by an attending surgeon, and proximity of the simulation center. The most preferred simulation tool was the live animal model followed by cadaveric tissue. Virtual reality simulators were among the least-preferred (25%) simulation tools. Most residents (91.0%) felt that mandatory/protected time in a simulation environment should be introduced into resident training protocols. CONCLUSIONS: Mandatory and protected time in a
simulation environment as part of the resident training curriculum may improve participation in simulation training. A comprehensive curriculum, which includes the use of live animals, cadaveric tissue, and virtual reality simulators, may enhance the laparoscopic training experience and C 2014 interest level of surgical trainees. ( J Surg ]:]]]-]]]. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.01.006
1
KEY WORDS: surgical education, laparoscopic skills training, resident participation, simulation, curriculum COMPETENCIES: Practice Based Learning and Improve-
ment, Systems Based Practice
INTRODUCTION Recent advances in surgical techniques, laparoscopic surgery in particular, require surgeons to master a unique set of psychomotor and visuospatial skills.1-6 These skills are necessary to overcome the specific challenges introduced by the laparoscopic approach: loss of depth perception, altered hand-eye coordination, changes in tactile feedback, the fulcrum effect, and working with elongated instruments. Other challenges facing surgical training today include work-hour limits, increased patient volume, demands for efficiency, and evolving requirements for objective proficiency. Simulation training for surgical residents can shorten learning curves, improve technical skills, and expedite competency. Furthermore, as numerous inherent traits and technical skill aptitudes affect individual learning, relying on an obligatory number of procedures performed in the operating room as the sole measure of proficiency may result in graduates with variable skills.7,8 As a result, much effort has been focused on developing efficient and effective training strategies for surgical residents and students in an environment outside the operating room, such as a surgical skills laboratory.9,10 Several studies have shown that technical skills learned in a simulation environment are transferrable to the operating room.4,11,12 Despite these positive and encouraging results, most surgical training programs continue to struggle with the integration of simulation-based training into the residents’ curricula,13 and simulation laboratories continue to be underutilized by surgical trainees.14 Chang et al.15 found that voluntary use of a simulation laboratory leads to minimal resident participation and mandatory participation was required for the training curriculum to be effective. Effective training tools in a skills laboratory include video box trainers, computer-based virtual reality (VR) simulators, inanimate models, and live animal models; however, there is no clear evidence of the superiority of one simulation tool over the other in skill acquisition.16 Furthermore, opinions regarding the most effective simulation tool differ between surgical educators and trainees.17,18 There is currently a paucity of data regarding residents’ opinions on minimally invasive simulation training. The purpose of this study was to explore resident perceptions, training experiences, and preferences regarding laparoscopic simulation training. Our goal was to profile resident participation in surgical skills simulation, recognize potential barriers to voluntary simulator use, and identify simulation tools and tasks preferred by residents before incorporating them into a formal skills training curriculum. 2
MATERIALS AND METHODS General surgery residents (postgraduate years [PGYs] 1-5) were recruited from Yale University School of Medicine, New Haven, CT, United States and the University of Toronto, Toronto, Ontario, Canada. Both institutions involved in this study had simulation laboratories available for use by general surgery residents. These laboratories house video box trainers, VR simulators, inanimate hernia models, and explanted tissue models. All residents also had scheduled sessions to practice on live anesthetized animal models as part of approved research protocols. Data were collected using an anonymous online questionnaire (www.surveymonkey.com) administered between November 1 to 31, 2011 and June 1 to 30, 2012. Two e-mail reminders were sent during each cycle of questionnaire administration. The questionnaire included 21 questions structured in rank-order, Likert-type, single answer, and multiple-choice formats. Demographics data, such as age, sex, level of training, and position type, were obtained. Questionnaire responses were coded and analyzed using STATA 12.1 (StataCorp, College Station, TX). Number “1” was defined as the highest possible rank for rank-order questions. Responses to rank-order questions were analyzed using one-way analysis of variance with Bonferroni post hoc correction for repeated measures. Likert-type questions required participants to provide responses on a scale from 1 to 5 corresponding to “Strongly Disagree,” “Disagree,” “Neutral,” “Agree,” and “Strongly Agree.” For the graphical representation of results, participants’ responses of “Agree” and “Strongly Agree” were combined into one “Agree” category and responses of “Disagree” and “Strongly Disagree” were combined into one “Disagree” category. The Fisher exact test was used for statistical analysis of Likert-type responses. This study was approved by the research ethics board of the University of Toronto and by the human investigation committee at Yale University School of Medicine. Informed consent was obtained if the participants chose to complete the online survey.
RESULTS A total of 43 of 78 (55.1%) residents at the University of Toronto and 24 of 67 (37.3%) residents at Yale University School of Medicine completed the online questionnaire, resulting in a combined response rate of 46.5%. The participants’ demographic data are presented in Table 1. With regard to ranking of model preferences by an entire group of study participants, live anesthetized animal was the most preferred model and the inanimate hernia model was the least preferred one (Table 2). There were significant differences between mean rank scores at p o 0.05 for the 5 models (F (4, 321) ¼ 10.45, p ¼ 0.0000). In post hoc comparisons, the mean rank score for live animal model was Journal of Surgical Education Volume ]/Number ] ] 2014
TABLE 1. Demographic Data for Questionnaire Participants University of Toronto Number of respondents (n; response rate %) Age (mean ⫾ SD [y]) Male (n; %) Female (n; %) Level of training (PGY) 1 2 3 4 5 Training position Categorical (n; %) Noncategorical (n; %) Fellowship interest Undecided Colon and rectal surgery Hand surgery Bariatric and minimally invasive surgery Pediatric surgery Plastic surgery Surgical oncology Surgical critical care/trauma/burn Thoracic surgery Transplantation Vascular surgery Other specialty
43 29.5 26 17 1 8 17 7 10
(55.1) ⫾ 3.1 (60.5) (39.5)
Yale University 24 29.5 19 5
(2.3%) (18.6%) (39.5%) (16.2%) (23.2%)
5 7 4 5 3
43 (100) 0
(37.3) ⫾ 2.1 (79.2) (20.8) (20.8%) (29.2%) (16.7%) (20.8%) (12.5%)
21 (87.5) 3 (12.5)
17 (39.5%) 1 (2.3%) 0 10 (23.3%) 1 (2.3%) 0 8 (18.6%) 1 (2.3%) 0 0 3 (7.0%) 2 (4.7%)
6 (25.0%) 3 (12.5%) 0 1 (4.2%) 2 (8.3%) 3 (12.5%) 2 (8.3%) 0 3 (12.5%) 1 (4.2%) 3 (12.5%) 0
Total 67 29.5 45 22 6 15 21 12 13
(46.5) ⫾ 2.8 (67.2) (32.8) (9.0%) (22.4%) (31.3%) (17.9%) (19.4%)
64 (95.5) 3 (4.5) 23 (34.3%) 4 (6.0%) 0 11 (16.4%) 3 (4.5%) 3 (4.5%) 10 (14.9%) 1 (1.5%) 3 (4.5%) 1 (1.5%) 6 (9.0%) 2 (3.0%)
SD, standard deviation.
significantly different (p o 0.05) from each of the other 4 models. The mean rank scores for video box trainer, VR simulator, inanimate hernia model, and explanted tissue were not significantly different from each other (p 4 0.05). However, the rankings for simulation models did differ based on a participant’s PGY of training (Fig. 1). PGY 1 trainees preferred video box trainers and VR simulators. PGY 2 trainees preferred live animal models and box trainers. PGYs 3 and 4 trainees preferred live animal models and practice on explanted tissues, whereas PGY 5 trainees preferred live animal models and box trainers. Intracorporeal knot tying was the most commonly practiced simulation task (Table 3). There were significant differences between the mean rank scores at p o 0.05 for the 6 commonly practiced simulation tasks (F (5, 378) ¼ 6.25, p ¼ 0.0000). In post hoc comparison, the mean rank score for intracorporeal knot tying was significantly different from pattern cutting (p ¼ 0.032), VR simulator–based curriculum (p ¼ 0.007), and VR simulator–based operative
procedure (p ¼ 0.000). The mean rank score for peg transfer was also significantly different from the mean rank score for the VR simulator–based operative procedure (p ¼ 0.003). The mean rank scores were not significantly different between all other commonly practiced tasks. Skill development, interest in minimally invasive surgery, and mandatory or protected time were cited as the top 3 reasons for using the simulation laboratory (Table 4). There were significant differences between the mean rank scores at p o 0.05 for the 9 reasons for using a simulation laboratory (F (8, 551) ¼ 18.28, p ¼ 0.0000). The top 2 reasons for residents not using a simulation laboratory were lack of time and being off campus for clinical rotations (Table 5). There were significant differences between the mean rank scores at p o 0.05 for the 4 reasons for not using a simulation laboratory (F (3, 256) ¼ 70.16, p ¼ 0.0000). In post hoc comparison, significant differences were demonstrated between the mean rank scores of the top 3 reasons of “lack of time,” “off campus/
TABLE 2. Ranking of Preferred Simulation Models Rank 1 2 2 4 5
Simulation Model
Mean Rank Score
Standard Error
Standard Deviation
Live animal model Explanted tissue Video box trainer Virtual reality simulator Inanimate hernia model
2.14 3.00 3.00 3.23 3.58
0.20 0.13 0.17 0.16 0.15
1.64 1.08 1.38 1.32 1.21
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FIGURE 1. Participants rankings of simulation models analyzed by postgraduate year of training.
off site,” “not necessary,” and the last reason of “not interested.” With regard to the timing of practice in a simulation laboratory, participants ranked “during work hours” as their top choice, followed by “postcall” and “off duty/on vacation” (Table 6). There were no significant differences between the mean rank scores at p o 0.05 for the 3 times for using a simulation laboratory (F (2, 196) ¼ 1.18, p ¼ 0.3095). The median amount of time that residents practiced per week in a simulation laboratory was 1 (0-1) hour. Simulators, which were used most of the time, were video box trainers (n ¼ 35; 68.6%) and VR simulators (n ¼ 4; 27.5%). Cadaveric tissue models (n ¼ 1; 2.0%) and inanimate models (e.g., hernia) (n ¼ 1; 2.0%) were rarely used. Only 2 of the 67 (3.0%) participants reported having a video box trainer at home; however, despite the availability of that simulator, the median amount of time practiced per week was only 1 (0-2) hour. Participants were also asked to comment on the need for mandatory time in a simulation laboratory. Of the 67 participants, 61 (91.0%) felt that mandatory participation in a simulation laboratory was essential. The median
number of hours suggested for practice in a simulation laboratory was 2 (2-3) hours per week. Participants were also asked to provide their opinions on the following 4 questions: Does simulation-based training improve laparoscopic skills? Are the skills acquired in a simulation laboratory transferable to the operating room? Is simulation training a good substitute for operating room exposure? Should a simulation-based curriculum be made mandatory before operating room exposure? Combining participants’ responses of “Agree” and “Strongly Agree” into one “Agree” category and responses of “Disagree” and “Strongly Disagree” into one “Disagree” category, 64 (95.5%) of the 67 participants agreed that simulationbased training improves laparoscopic skills (p o 0.0001) (Fig. 2). Of the 67 participants, 62 (92.5%) agreed that skills acquired in a simulation laboratory are transferable into the operating room (p o 0.0001). Of the 67 participants, 43 (64.2%) disagreed that simulation training is a good substitute for operating room exposure (p o 0.0001), whereas 38 (56.7%) agreed that proficiency in a simulationbased curriculum should be mandatory before operating room exposure (p ¼ 0.0019).
TABLE 3. Ranking of Commonly Practiced Simulation Tasks Rank 1 2 3 4 5 6
4
Simulation Task Intracorporeal knot tying Peg transfer Extracorporeal knot tying Pattern cutting Virtual reality simulator–based curriculum Virtual reality simulator–based operative procedure
Mean Rank Score
Standard Error
Standard Deviation
2.73 3.08 3.38 3.64 3.77 4.18
0.24 0.17 0.22 0.16 0.23 0.21
1.89 1.37 1.73 1.26 1.84 1.73
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TABLE 4. Ranking of Reasons for Using the Simulation Laboratory Rank 1 2 3 4 5 6 7 8 9
Reason
Mean Rank Score
Standard Error
Standard Deviation
Skill development Interest in minimally invasive surgery Mandatory or protected time Practice before a case Requirement for a rotation Recommendation of an attending surgeon Proximity to the simulation lab Free time Peer pressure
2.48 4.23 4.35 4.87 5.32 5.39 5.56 5.57 7.11
0.28 0.32 0.35 0.26 0.30 0.26 0.28 0.28 0.32
2.22 2.54 2.73 2.06 2.38 2.11 2.23 2.15 2.49
DISCUSSION We used a cross-sectional survey design to characterize general surgery trainees from 2 academic training programs in North America in terms of demographics, attitudes, training experiences, and preferences toward laparoscopic simulation training. The anonymous and voluntary nature of the online survey encouraged true reporting and minimized reporting bias. Our study revealed several interesting findings. Overall, the high-fidelity live animal model was the most preferred simulation tool. The advantages of these models are the realism of the tissue, similarity to human anatomy, and opportunities to mimic intraoperative complications. The disadvantages of these models are the costs, requirement for mentor supervision, and ethical concerns regarding the use of live animals.16 Having had more experience in the operating room, the senior residents preferred the live animal model, possibly perceiving the VR simulation and inanimate models as less stimulating. Overall, VR simulation was among the least-favored simulation tool among the residents. This is in contrast to the opinion of surgical educators who perceive VR simulators as one of the most effective tools, second only to the operating room experience.17 From the surgical educator’s perspective, VR simulation affords minimal supervision during training, versatile customized curricula, opportunity
for deliberate practice, and an objective means for tracking trainee performance.19 Such models also allow the user to simulate complications in a risk-free environment. However, the trainees notice a lack of realism in the graphics and find the forced feedback, when available, to be limited or unrealistic. VR simulators also have a high initial start-up cost, and there are a large variety of simulators in the market offering a wide range of tasks, curricula, and procedures, thus making comparisons and validation difficult.16 Our study highlights potential trainee resistance among senior residents to learning on these models. Interestingly, our study showed that simulation tool preferences vary with the resident’s training level. We found that junior surgical residents prefer to train on VR simulators and box trainers, whereas senior residents prefer to train on live animal and explanted tissue models. This information can be considered by surgical educators when developing simulation-based training curricula. Junior residents can be started on VR simulators, and their skills can be improved by using validated and customized proficiencybased curricula,20,21 thus minimizing the need for mentor supervision. Senior residents can practice on explanted tissue and live animal models with appropriate faculty supervision, thereby using valuable faculty resources most effectively. We must also emphasize that training on a simulator in isolation may not be as beneficial as training on various
TABLE 5. Ranking of Reasons for Not Using the Simulation Laboratory Rank 1 2 3 4
Reason
Mean Rank Score
Standard Error
Standard Deviation
Lack of time Off campus/off site rotation Not necessary Not interested
1.61 1.88 3.02 3.42
0.12 0.09 0.09 0.12
0.97 0.70 0.70 0.96
TABLE 6. Ranking of Times for Using a Simulation Laboratory Rank 1 2 3
Timing
Mean Rank Score
Standard Error
Standard Deviation
During work hours Postcall Off duty/on vacation
1.92 1.94 2.12
0.12 0.08 0.10
0.95 0.67 0.81
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FIGURE 2. Participants’ opinions as rated on a Likert-type scale.
simulation models as part of a comprehensive training curriculum that addresses multiple components of surgical competency. Clinical performance should be assessed using objective, reliable, and valid assessment tools for technical and nontechnical skills. One algorithm to follow in designing such curricula is to use a recently published framework for design, validation, and implementation of simulationbased training curricula in surgery.22 Palter and Grantcharov23 recently demonstrated how to develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. The most commonly practiced tasks by the residents were the Fundamentals of Laparoscopic Surgery (FLS) tasks and intracorporeal knot tying in particular. An increased use of the video box trainer was noticed among the fifth-year residents to perform these tasks. A factor responsible for this may be the requirement for Fundamentals of Laparoscopic Surgery certification during the fifth year to qualify for the American Board of Surgery examination. As expected, internal motivating factors, such as skill development and a fellowship interest in minimally invasive surgery, were the most often cited reasons for using the simulation laboratory. However, work-hour restrictions, clinical responsibilities, and limited free time often negatively affect internal motivating factors. An external motivating factor, such as mandatory and protected time— instituted rarely in our institutions—was another common reason for simulator use. Most residents believed that simulation training improved skills and transferred to the operating room, yet few found the time during their workweek to practice their skills. Should the onus to make the time for simulation training be up to each individual resident? Studies have shown that introducing mandatory participation in simulation training with punitive measures for low attendance improves participation.14 Currently, the core of the mandatory education curriculum for most residency programs consists of scheduled teaching conferences, didactic sessions, grand rounds, journal clubs, and mock oral examinations. The time spent in these educational activities is counted toward duty hours to be compliant with the Accreditation
Council for Graduate Medical Education (ACGME) Program requirements.24 Our study shows that an overwhelming majority of residents were in favor of incorporating at least 2 hours per week of mandatory/protected time in a simulation environment as part of the resident education curriculum. This study has a number of strengths and adds to the literature in many ways. First, it successfully elicits trainee perceptions and experiences and identifies varying preferences among training levels. Second, this study also demonstrates common barriers to voluntary participation and provides an insight into the discrepancy between what residents desire and what is current practice. Third, the study also includes residents from 2 institutions with different training systems, which may add to the generalizability of the results. This study has a few limitations. First, it has a relatively low response rate; however, this is in keeping with survey responses among physicians.25 Second, this study includes participants from 2 similar academic training programs; both with well-equipped simulation laboratories. Third, these findings may not generalize to smaller programs, and larger studies at a national level are required to further investigate these findings.
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CONCLUSION This study informs us about resident preferences and training patterns, which could be factored when setting up a surgical skills curriculum. A comprehensive curriculum that includes the optimal use of the live animal models, video box trainers, and VR simulators with structured proctoring during the sessions may enhance the laparoscopic training experience for surgical trainees.
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